A nurse is caring for a 15-year-old adolescent who is admitted with a vaso-occlusive crisis in the emergency department.
Select the 5 interventions the nurse should include.
Apply cold compresses to the affected joints.
Administer meperidine IV for pain.
Administer folic acid as prescribed.
Restrict oral intake.
Give oral hydroxyurea.
Monitor oxygen saturation continuously.
Place the client on strict bed rest.
Instruct the parent to ensure the pneumococcal vaccine is current
Correct Answer : C,E,F,G,H
Choice A rationale: Applying cold compresses to the affected joints is not recommended for vaso-occlusive crises in sickle cell disease. Cold can cause vasoconstriction, which may worsen the pain and decrease blood flow to the affected areas. Warm compresses are preferred to promote vasodilation and improve blood flow.
Choice B rationale: Administering meperidine IV for pain is not recommended due to the risk of neurotoxicity and the potential for seizures with repeated use. Other opioids, such as morphine or hydromorphone, are preferred for managing severe pain in vaso-occlusive crises.
Choice C rationale: Administering folic acid as prescribed is important for clients with sickle cell disease. Folic acid helps in the production of new red blood cells, which is crucial for individuals with sickle cell disease who experience chronic hemolysis and anemia.
Choice D rationale: Restricting oral intake is not necessary for a client with a vaso-occlusive crisis unless there are specific medical indications. Adequate hydration is essential to help reduce the viscosity of the blood and prevent further sickling of red blood cells.
Choice E rationale: Giving oral hydroxyurea is important for managing sickle cell disease. Hydroxyurea helps to increase the production of fetal hemoglobin, which reduces the frequency and severity of vaso-occlusive crises. It is a key medication in the long-term management of sickle cell disease.
Choice F rationale: Monitoring oxygen saturation continuously is important to ensure that the client is receiving adequate oxygenation. Hypoxia can exacerbate sickling of red blood cells and worsen the vaso-occlusive crisis. Continuous monitoring allows for prompt intervention if oxygen levels drop.
Choice G rationale: Placing the client on strict bed rest is important to reduce metabolic demands and prevent further pain and complications. Rest helps to conserve energy and reduce the risk of additional stress on the body during a vaso- occlusive crisis.
Choice H rationale: Instructing the parent to ensure the pneumococcal vaccine is current is important for preventing infections. Clients with sickle cell disease are at increased risk for infections, particularly with encapsulated bacteria like Streptococcus pneumoniae. Keeping vaccinations up to date is crucial for reducing the risk of serious infections.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
Bradypnea, or slow breathing, is a common and serious side effect of morphine, especially in children. It requires immediate attention.
Choice B rationale
Morphine does not typically affect wound healing. This is more associated with corticosteroids.
Choice C rationale
Morphine can cause hypotension, not hypertension.
Choice D rationale
Stevens-Johnson syndrome is a rare but severe reaction to medications, including some antibiotics and anticonvulsants, but not commonly associated with morphine.
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
An increase in potassium levels is not an indicator of the effectiveness of furosemide, which is a diuretic used to reduce fluid overload.
Choice B rationale
A decrease in peripheral edema indicates that furosemide is effectively reducing fluid retention in the body.
Choice C rationale
A decrease in cardiac output is not a desired effect of furosemide and may indicate worsening heart function.
Choice D rationale
An increase in venous pressure is not an indicator of the effectiveness of furosemide and may suggest fluid overload.
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